Managing the Dental Patient with a Seizure Disorder Epilepsy

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Managing the Dental Patient with a Seizure
Disorder (Epilepsy)
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Historical/Famous Figures With Epilepsy
Elton John
Napoleon
Danny Glover
Alexander
Charles Dickens
Einstein
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Seizures

• A seizure is a sudden excessive discharge of
  electrical activity in the brain that usually
  causes a change in behavior some seizures can
  hardly be noticed while others are totally
  disabling
• Seizures do not constitute a disease in and of
  themselves but rather are a symptom of an
  underlying disorder that affects the brain
• Isolated, nonrecurring seizures are relatively
  common and occur in many medical or neurological
  illnesses such as febrile illness, head injury,
  or hypoglycemia these are usually self-limiting
  and cease with correction of the underlying cause
• About 5-10 of the population will have a seizure
  of some type during their lifetime
• About 1 of the population in the US (2.3
  million) has recurring seizures (epilepsy)

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Common Causes of Acute, Non-persistent Seizures

• Metabolic abnormalities (e.g. hypoglycemia, acute
  alcohol intoxication)
• Drug induced (e.g. lidocaine)
• Acute head trauma
• Brain tumors
• Brain abscess
• Stroke
• Meningitis encephalitis
• Illnesses (e.g. eclampsia, hypertensive
  encephalopathy)

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Epilepsy

• A disorder characterized by transient, recurrent
  disturbances of brain function that may or may
  not be associated with impairment or loss of
  consciousness and abnormal movements or behavior
• Most epileptic seizures occur randomly, however
  some occur with triggering events such as
• Missing a dose of antiepileptic medication
• Flashing, flickering, or strobe lights
• Certain times in the menstrual cycle
• Stress
• Lack of sleep
• Excessive alcohol ingestion
• Infection
• Dehydration or starvation
• High fevers (in children)

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Types of Epileptic Seizures

• Seizures are classified by their clinical
  manifestations along with EEG data
• Clinical manifestations depend upon
• What part of cerebral cortex is involved
• The function of that part of the involved cortex
• The subsequent pattern of spread within the brain
• Degree of cortical involvement by EEG
• Partial or focal seizures limited to one part of
  the brain
• Generalized seizures diffusely involving the
  entire cortex

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EEG (Electroencephalograph)

• An electrical recording of brain activity as
  measured by a series of electrodes placed on the
  head and scalp

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Types ofEpileptic Seizures

• Partial Seizures (involve only a part of the
  brain may not lose consciousness)
• Simple partial last no more than a few seconds
  and in most cases do not affect consciousness
  sometimes the person will just notice a transient
  unusual feeling or sensation (strange taste,
  muscle twitching, numbness)
• Complex partial occur through a wider area of
  the brain consciousness is altered and sometimes
  the person will stop speaking, act strangely, or
  have repetitive movements.
• Secondarily generalized seizures Simple or
  complex partial seizures that start in one part
  of the brain and then spread through the entire
  brain. Once the entire brain is affected, there
  can be a loss of consciousness and shaking of the
  entire body (convulsions).
• Generalized Seizures (involve all or most of
  brain with loss of consciousness no memory of
  occurrence)
• Tonic-clonic (grand mal) seizures loss of
  consciousness with convulsions
• Absence (petit mal) seizures brief loss of
  consciousness eye fluttering

Of most significance for dentistry
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Clinical Spectrum of Epilepsy Symptoms

• Seizures may be expressed clinically in a myriad
  of ways depending upon which area of the brain is
  involved and the extent of involvement
• Motor effects varies from a single jerk of a
  single muscle to rhythmic persistent jerks of the
  entire body also may see a complete loss of
  muscle tone with a resultant fall or drop attack
• Sensory effects strange smells or taste, visual
  or auditory hallucination, feeling of pins and
  needles, or numbness
• Higher level functions confusion or unusual
  behaviors
• The grand mal seizure is the most dramatic and of
  most concern in the dental setting

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Simple Partial Seizures

• Incidence highest in older adults
• No loss of consciousness
• Usually brief (seconds-minutes)
• Motor, sensory or psychomotor phenomena
• Localized twitching of muscles
• Chewing movements, smacking lips
• Localized numbness, tingling
• Olfactory or visual hallucinations
• May have nausea, sweating, skin flushing, and
  dilated pupils

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Complex Partial Seizures

• Impaired consciousness with decreased
  responsiveness and awareness of self and
  surroundings lasting 30 sec. to 2 min
• Often begins with a brief aura
• Staring, performance of automatic, purposeless
  movements (chewing, fumbling, picking), mumbling
• May have nausea, sweating, skin flushing, and
  dilated pupils
• Recalled or inappropriate emotions
• Olfactory and gustatory hallucinations
• Mental confusion after attack

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Generalized Absence (Petit Mal) Seizures

• Most common during childhood age 6-12
• 10-30 second loss (absence) of consciousness
  (blank stare)
• Eyelid flutterings at 3/sec
• Patients do not fall or convulse
• Abruptly stops activity and resumes as abruptly
  no memory of occurrence
• No post-ictal symptoms
• Occurs many times per day often while sitting
  quietly may be precipitated by hyperventilation

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Generalized Tonic-Clonic (Grand Mal) Seizures

• Aura, then often followed with an epileptic cry
• Loss of consciousness and falling to the ground
• Tonic, then clonic contractions of extremities,
  trunk, head
• Temporary cessation of breathing tongue/cheek
  biting
• Urinary incontinence
• Usually lasts less than 90 seconds
• Post-ictal state (transient deep sleep, followed
  by headache, confusion, muscle soreness)

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Diagnosis and Medical Management

• History
• Clinical exam EEG video-EEG, MRI, computed
  axial tomography (CAT), lumbar puncture, serum
  chemistry, and toxicology screening
• Treat identifiable causes
• Pharmacotherapy (Anticonvulsants)
• Drugs of choice vary with the type of
• seizure
• Single drug therapy is often effective
• 25 of seizures cannot be completely controlled
  with medications
• Surgical therapy
• Vagus nerve stimulation

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Anticonvulsants

• Acetazolamide (Diamox)
• Carbamazepine (Tegretol)
• Clonazepam (Klonopin)
• Ethosuximide (Zarontin)
• Fosphenytoin (Cerebix)
• Gabapentin (Neurontin)
• Pregabalin (Lyrica)
• Tiagabine (Gabatril)
• Levetiracetam (Keppra)

• Lamotrigene (Lamictal)
• Oxcarbazepine (Trileptal)
• Phenobarbital (Luminal)
• Phenytoin (Dilantin)
• Primidone (Mysoline)
• Topiramate (Topamax)
• Valproate (Depakote)
• Zonisamide (Zonegran)

These drugs reduce the frequency of seizures by
elevating the seizure threshold of motor cortex
neurons, depressing abnormal electrical
discharge, and limiting the spread of excitation
from abnormal foci
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Different drugs are used to treat different types
of seizures Examples

• Simple and complex partial seizures
• Carbamazepine, oxcarbamazepine, lamotrigine,
  valproate, topiramate, levetiracetam, phenytoin,
  zonisamide, gabapentin
• Generalized tonic-clonic seizures
• Valproate, lamotrigine, zonisamide, topiramate,
  levetiracetam

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Surgical Treatment for Epilepsy

• Indicated when epilepsy is not adequately
  controlled by medication
• Four basic surgical procedures are used
• Standard (mesial) temporal lobectomy excellent
  prognosis with 80-90 of patients rendered
  seizure-free
• Focal brain resection of the epileptogenic tissue
  of neocortical origin prognosis is good if
  specific area is identified other than mesial
  temporal lobe
• Corpus callosotomy performed in patients with
  atonic seizures (drop attacks) with good seizure
  control following surgery
• Hemispherectomy performed in patients with
  intractable seizures involving an entire
  hemisphere seizure reduction is usually good

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Vagus Nerve Stimulator

• Used to treat refractory epilepsy
• Based on finding that vagal stimulation produces
  anticonvulsant effects
• A two part device with one end wrapped around the
  vagus nerve and the other resembling a pacemaker
  (generator) that is implanted under the skin
  beneath the clavicle
• Programmed to generate an impulse on a regular
  basis or on demand
• Used as an adjunct to pharmacology
• No interference by electrical dental equipment
  (Roberts JADA,2002)
• Antibiotic prophylaxis not indicated for dental
  treatment

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Anticonvulsants are commonly used to treat other
disorders

• Neuralgias (trigeminal neuralgia,
  glossopharyngeal neuralgia)
• Continuous neuropathic pain (atypical toothache,
  burning mouth)
• Psychoses
• Headaches

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Dental Management

• Identification of patient with seizure disorder
  (Medical History) generalized grand mal seizures
  are of most concern in the dental setting
• Establish history of seizure disorder (type, when
  diagnosed, severity, frequency, degree of
  control, last seizure, precipitating factors)
• Medications
• Compliance
• Patients with epilepsy are often not compliant
  with their medications

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Dental Management

• Patient with
• Well controlled seizure disorder provide normal
  care avoid triggers (if any) consider possible
  drug side-effects be prepared to manage a
  seizure
• Poorly controlled, non-compliant, or with a
  questionable history consultation with
  physician is advised prior to treatment patient
  may need adjustment of medications if further
  improvement of control not possible, may need to
  be treated in a special care setting such as GPR
  or hospital dentistry

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Adverse Drug Effects

• All anticonvulsant drugs can cause adverse
  effects (either dose related or idiosyncratic)
• Dose related (most common)
• sedation, dizziness, somnolence, nausea
• Idiosyncratic (potentially serious and
  life-threatening)
• rash, Stevens-Johnson syndrome, agranulocytosis,
  thrombocytopenia, aplastic anemia, liver failure
• 25-30 of patients with epilepsy have a minor
  elevation of hepatic aminotransferase levels
  (i.e. AST, ALT) that is not clinically relevant

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Carbamazepine/Oxcabazepine

• 20 of patients taking carbamazepine (Tegretol)
  or oxcarbazepine (Trileptal) experience a benign
  leukopenia with WBC counts of less than 4000/mL,
  with transient decreases to less than 2500/mL
• The risk of aplastic anemia is not greater for
  this group
• There is no increase risk of infection in this
  group

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Adverse Oral Effects

• Phenytoin (Dilantin)
• Gingival hyperplasia etiology unknown found in
  about 50 of patients taking phenytoin usually
  evident within 2-18 months after starting
  treatment good OH can prevent or minimize the
  occurrence

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Specific Dental Concerns

• Traumatic injuries following a convulsive seizure
  are common
• Tooth fractures devitalization (delayed)
• Jaw/alveolar fractures
• Soft tissue injuries (tongue, cheek, lips)
• Treatment planning considerations
• Do you replace missing teeth? Fixed vs removable?

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Management of a Grand Mal Seizure

• Be alert to signs or symptoms of a pending
  seizure (aura, strange feeling, etc)
• If patient is standing, support them and lower
  them to the ground
• Remove potentially harmful objects from around
  patient
• Prevent injury to the patient by loosely or
  passively restraining them
• Loosen tight clothing around neck
• Do not try to pry teeth apart or attempt to place
  anything between teeth once the seizure has
  started
• Stay with patient until seizure subsides (usually
  within 1-2 minutes)
• Maintain airway and administer oxygen / monitor
  vital signs
• As patient regains consciousness, reassure them
  as they may be confused and embarrassed
• Examine for injuries and treat if necessary
• Notify physician of the occurrence

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Status Epilepticus (Convulsive)

• A medical emergency
• A continuous seizure that lasts longer than 30
  minutes or a series of seizures without full
  recovery in between lasting for more than 30
  minutes
• May be the first manifestation of epilepsy in
  about 10 of cases
• In 50-65 of patients there is a precipitating
  factor (metabolic abnormalities, drug abuse,
  hypoxia, infection, stroke, tumor)
• The patient can quickly become seriously hypoxic
  and acidotic resulting in permanent brain damage
  or death. Mortality rate of about 30 in adults.
• Treatment
• Activate the EMS
• Maintain airway and administer oxygen
• Establish IV access and administer a
  benzodiazepine
• Lorazepam (Ativan) 4-8 mg IV over 2 minutes
• Diazepam (Valium) 10-20 mg IV over 2 minutes